Opportunities to improve quality of care for cancer survivors in primary care: findings from the BETTER WISE study

Purpose The BETTER WISE (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care for Wellness of Cancer Survivors and Patients) intervention is an evidence-based approach to prevention and screening for cancers and chronic diseases in primary care that also includes comprehensive follow-up for breast, prostate and colorectal cancer survivors. We describe the process of harmonizing cancer survivorship guidelines to create a BETTER WISE cancer surveillance algorithm and describe both the quantitative and qualitative findings for BETTER WISE participants who were breast, prostate or colorectal cancer survivors. We describe the results in the context of the COVID-19 pandemic. Methods We reviewed high-quality survivorship guidelines to create a cancer surveillance algorithm. We conducted a cluster randomized trial in three Canadian provinces with two composite index outcome measured 12 months after baseline, and also collected qualitative feedback on the intervention. Results There were 80 cancer survivors for whom we had baseline and follow-up data. Differences between the composite indices in the two study arms were not statistically significant, although a post hoc analysis suggested the COVID-19 pandemic was a key factor in these results. Qualitative finding suggested that participants and stakeholders generally viewed BETTER WISE positively and emphasized the effects of the pandemic. Conclusions and implications for cancer survivors BETTER WISE shows promise for providing an evidence-based, patient-centred, comprehensive approach to prevention, screening and cancer surveillance for cancer survivors in the primary care setting. Trial registration ISRCTN21333761. Registered on December 19, 2016, http://www.isrctn.com/ISRCTN21333761. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-023-07883-4.


Purpose of this document
This document was prepared from the recommendations made by the Clinical Working Group for items regarding primary prevention and screening for cancer, cardiovascular disease and diabetes (including lifestyle factors). Information on the criteria identified for each item or "criteria for eligibility (E)" AND "criteria for achievement (A)" listed within is to be collected and analyzed for the project's primary analysis. All recommendations were based on 2017 guidelines to improve quality in family practice. Table which define the referrals/actions patients are deemed eligible (E) to achieve based on assessments at the baseline evaluation and the criteria that must be met in order for a patient to have achieved (A) each referral/action they have been determined to be eligible for. All CCDPS items identified by the Clinical Working Group have been compiled to create the BETTER WISE Main Composite Index. These items include process, referral/treatment, and target/change actions. As there is an association between process measures, referral/treatment actions, and patient outcomes (target/change outcomes), items encompassing these three areas have been included in the Main Composite Index.

This document contains the Cancer and Chronic Disease Prevention and Screening (CCDPS) Composite Index
o The BETTER WISE Main CCDPS Composite Index Table (Section B.1), defines the criteria used to calculate the main outcome CCDPS composite index for the project. The items described in this table allow for a calculation of the proportion change in unachieved CCDPS items for each patient and includes process, referral/treatment, and target/change actions. This composite index is calculated at follow-up (12 and 24 months, where applicable). The eligible actions are determined at baseline using the "criteria for eligibility (E)" and at each follow-up evaluation the achievement of the eligible actions is assessed using the "criteria for achievement (A)". o Where the term Health Professional appears in this document, it refers to Primary Care Practitioner, Nurse, Nurse Practitioner, Prevention Practitioner, Dietician, Nutritionist, Pharmacist, and Clinical Assistant.
• Indicators and Ranges (Section C), which specify the targets/ranges used to determine a patient's eligibility (E) for and achievement (A) of the referrals/actions included in the composite index at each evaluation time point (i.e. baseline, 12 month, and 24 month, where applicable).

SECTION B: CDPS PRIMARY PREVENTION & SCREENING COMPOSITE INDEX TABLE
Defines the criteria used to calculate the main composite index for the project, which includes monitoring and screening actions. This composite index is calculated at each follow-up evaluation (12 and 24 month, where applicable). The eligible actions are determined at baseline using the "criteria for eligibility (E)" and at each evaluation, the achievement of the eligible actions is assessed using the "criteria for achievement (A)". Items followed by a "*", "**", "***" are process outcome, referral/treatment outcome or target/change outcomes, respectively. Cervical Cancer Screen* All women without personal history of cervical cancer AND with no abnormalities detected in previous pap tests AND without a hysterectomy with removal of the cervix AND who are not immunocompromised (see Section C) that have not completed routine cervical cancer screening in the past 3 years Pap test complete [23][24][25][26] All women without personal history of cervical cancer AND with no abnormalities detected in previous pap tests AND without a hysterectomy with removal of the cervix AND who are immunocompromised (see Section C) that have not completed routine cervical cancer screening in the past year Pap test complete 8 CVD risk assessment All men > 40 years old without established CVD or familial hypercholesterolemia whose CVD risk has not been assessed in the past 3 years using QRISK2 or Framingham CVD risk assessment completed using QRISK2 2,3,27,28 All women > 50 years old without established CVD or familial hypercholesterolemia whose CVD risk has not been assessed in the past 3 years using QRISK2 or Framingham CVD risk assessment completed using QRISK2 All women 40-50 who are post-menopausal without established CVD or familial hypercholesterolemia whose CVD risk has not been assessed in the past 3 years using QRISK2 or Framingham CVD risk assessment completed using QRISK2 All patients 40-65 with type 2 diabetes without established CVD or familial hypercholesterolemia whose CVD risk has not been assessed in the past 3 years using QRISK2 or CVD risk assessment completed using QRISK2 Framingham 9 ACE/ARB treatment All patients 40-65 without established CVD or familial hypercholesterolemia not currently on an ACE or ARB, but there is evidence for prescribing the medication (See Section C).
Referral to primary care provider for ACE/ARB discussion. Cholesterol Treatment** All men > 40 years old without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 10%, but < 20% AND not on a statin • Discussion with primary care provider, internal resource or external resource in progress or complete for cholesterol medication discussion and management. 27 All women > 50 years old without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 10%, but < 20% AND not on a statin • Discussion with primary care provider, internal resource or external resource in progress or complete for cholesterol medication discussion and management. All women 40-65 who are post-menopausal without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 10%, but < 20% AND not on a statin • Discussion with primary care provider, internal resource or external resource in progress or complete for cholesterol medication discussion and management. All patients 40-65 with type 2 diabetes without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 10% AND not on a statin

•
Discussion with primary care provider, internal resource or external resource in progress or complete for cholesterol medication discussion and management. All men > 40 years old without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 20% AND not on a statin Prescribed cholesterol medication (e.g. statin) All women > 50 years old without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 20% AND not on a statin Prescribed cholesterol medication (e.g. statin) All women 40-65 who are post-menopausal without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 20% AND not on a statin Prescribed cholesterol medication (e.g. statin) All patients 40-65 with type 2 diabetes without established CVD or familial hypercholesterolemia whose QRISK2 cardiovascular risk score is ³ 20% AND not on a statin If there is no abnormal cytology, no personal history of cervical cancer, no personal history of a hysterectomy with removal of the cervix AND: • Patient is not immuno-compromised, pap test every 3 years Patient is immune-compromised, pap test every year [23][24][25][26] Cervical cancer and immuno-compromised For the purposes of cervical cancer screening, immuno-compromised is defined as meeting any of the following: • Organ transplant recipient OR • Chronic use of corticosteroids (i.e. a prescription ³1 month) OR • Prescription of an alkylating agent OR • Prescription of an antimetabolite OR 25,56